A 270 degree laparoscopic posterior fundoplasty in the treatment of gastroesophageal reflux.

BACKGROUND: The aim of this prospective study was to evaluate the results of laparoscopic treatment of gastroesophageal reflux using a posterior fundoplasty. STUDY DESIGN: Fifty-one patients with gastroesophageal reflux or paraesophageal hernia, or both, documented by fibroscopy, acid reflux monitoring, and manometry were evaluated. The operative technique consisted of abdominal esophagus mobilization, approximation of the crura, and construction of a 270 degree posterior gastric valve, 5 to 7 cm in height. A clinical examination was performed after two weeks, four months, one year, and two years, and fibroscopy, acid reflux monitoring, and manometry were done at four months. RESULTS: One patient required a conversion to laparotomy. One opening of the gastric valve was repaired laparoscopically. There was no perioperative death. Morbidity was limited to one case of pulmonary aspiration of gastric juice. All patients but one who were operated on laparoscopically have been clinically evaluated between four and six months after surgery. There was no dysphagia, diarrhea, or gas bloating reported after two months. Four patients without clinical symptoms refused to go through postoperative explorations. Among the 45 remaining patients, one had a reflux recurrence and another only an abnormality on acid reflux monitoring. There was no degradation of the clinical result among the 26 and 12 patients seen at one and two years, respectively. CONCLUSIONS: A 270 degree posterior fundoplasty can be performed laparoscopically without major morbidity. A short follow-up examination confirms the efficacy of the procedure and the absence of specific morbidity. If these results are confirmed, they could be an argument to broaden the indications of the antireflux procedure as compared to prolonged medical treatment.

Laparoscopic hepatic sonography.

Laparoscopic hepatic sonography is becoming a standard procedure with the arrival of specifically designed probes. The technique of liver exploration used in open surgery has to be adapted. The technique we propose is initiated by a sagittal sonography associated with rotation movements. The basic exploration follows firstly the hepatic veins and then the portal branches. During the period of vascular exploration, the corresponding liver parenchyma is examined. As the quality of the laparoscopic sonography is becoming equivalent to that observed in open surgery, in the near future the results of laparoscopic and open surgery sonography will probably be identical.

Teleconsultation before chemotherapy for recently operated on patients.

BACKGROUND: Some operated on cancer patients require specialized complementary chemotherapy. Often, this takes place in another institution, where the patient consults the medical oncologist before hospitalization. The aim of this study was to analyze the potential benefit of a videoconference consultation within this framework. METHODS: Sixteen operated on cancer patients hospitalized in the Surgical Unit received a teleconsultation in the presence of their surgeon and with the chemotherapist at some distance. During this period, the modalities of chemotherapy proposed, the duration of the teleconsultation, the economy of transport, and so on were noted. Twenty-four hours later each patient filled in a questionnaire aimed at, one, evaluating the quality of the image on an visual analogue scale (VAS) and the potential inconvenience involved; and two, evaluating the index of patient satisfaction on VAS. Furthermore, the last 12 patients filled in a questionnaire adapted to each of them, according to the information they had received. Each correct answer was noted 1, and each incorrect answer was noted 0. A memorization percentage was deduced. RESULTS: The average age of the 16 patients was 63.4 years (range 46 to 78). The average duration of the teleconsultation was 27 minutes (12 to 40). The index of image satisfaction was 61.3%. As for the last 12 patients, 9.8 questions (7 to 12) enabled the calculation at 24 hours of the percentage of data retained by the patient (memorization index) based on the modalities and consequences of the chemotherapy. The percentage of correct answers was 80.5%. Fourteen of the 16 patients considered that teleconsultation had its advantages. Two patients would have preferred a classic consultation. The global satisfaction index was 79.9%. The average cost of functioning per patient was 187.76 FF A saving in transport of 509.92 FF was recorded per patient. CONCLUSIONS: In the context of this original study, teleconsultation neither altered the doctor-patient relationship nor the quality of the message transmitted. Furthermore, it encourages closer links between complementary teams working at a distance and multidisciplinarity in cancerology.

Does laparoscopic colorectal resection for diverticular disease impair male urinary and sexual function?

BACKGROUND: Laparoscopic colorectal resection may induce bladder and sexual dysfunction secondary to injury to the autonomic nervous system. The aim of this study was to evaluate urinary and sexual function in male patients after laparoscopic colorectal resection for diverticular disease. METHODS: From January 1997 to March 2002, we performed a retrospective analysis of urinary and sexual function in 56 consecutive male patients who had undergone laparoscopic colorectal resection for diverticular disease. Preoperative and 6-month postoperative assessment was carried out using data collected via standardized postal questionnaires. RESULTS: Three patients were excluded (one had a prior prostatectomy, one had Peyronie's disease, and one was treated with neuroleptics). Fifty-three patients with a mean age of 54 A+/- 2 years were included in the study. There were no conversions. The morbidity rate was 9.4%. Mean follow-up was 27 A+/- 2 months. There was no significant difference in preoperative and postoperative urinary function. Fifty-one patients (96%) were sexually active preoperatively and were still sexually active postoperatively. Compared with the preoperative period, postoperative impairment of libido, erection, ejaculation, and orgasm were not significant. Every patient was able to achieve ejaculation after the intervention, and no retrograde ejaculations were reported. One patient was unable to have an erection after the intervention. CONCLUSION: Laparoscopic colorectal resection for diverticular disease does not significantly impair urinary and sexual function.

[Endorectal ultrasonography: evaluation of locoregional extension of cancers of the rectum]. / L'échographie endo-rectale: appréciation de l'extension loco-régionale des cancers du rectum.

The treatment of rectal carcinoma is mainly determined by its local extension, which is difficult to assess before surgery. Our purpose was to determine the reliability of endorectal echography (ERE) in order to provide preoperative assessment of local extension of rectal tumors. Twenty-five patients with rectal adenocarcinoma were included in this study. Seventeen tumors could be felt by rectal examination. ERE was impossible in one case. Echographic data were compared with anatomic findings in 24 patients. ERE provided an accurate assessment of the parietal involvement in 22 cases. The sensitivity and specificity of ERE in determining the spread of the tumor to the rectum alone were 1 and 0.89, respectively, superior to the results provided by clinical examination alone (sensitivity 0.84-specificity 0.76). When the results of the two investigations were identical, all patients were well classified. For lymph node involvement, the sensitivity and specificity of ERE were 0.71 and 0.76 respectively. These results show that ERE is one of the best investigations currently available for assessing parietal involvement of rectal tumors. ERE might be able to determine the appropriate place of radiation therapy, local excision or anal sphincter preservation.

[Epidermoid cancer of the thoracic esophagus following mediastinal irradiation]. / Cancer épidermoïde de l'oesophage thoracique après irradiation médiastinale.

Squamous cell carcinoma of the esophagus induced by radiation therapy is a rare entity. We report 4 cases observed during the past 4 years. Three women and one man aged from 47 to 78 years developed squamous cell carcinoma of the esophagus 8 to 11 years after radiation therapy. The 3 women had been irradiated for breast cancer and the man for Hodgkin's disease with 40 to 57.5 Gy. Three patients were operated on and the immediate postoperative course was uneventful. Culling data from this report and from the literature we reviewed the different steps concerning the diagnosis and the treatment of this complication of radiation therapy. We suggest that diagnostic and therapeutic modalities should follow the same guidelines as in other esophageal cancers.

[Post-surgical or traumatic anal incontinences. Prospective study in 40 patients explorated by endorectal ultrasonography and electromyography]. / Incontinences anales post-chirurgicales ou traumatiques. Etude prospective de 40 malades explorés par échographie endorectale et électromyographie.

OBJECTIVES: Anal endosonography is used to assess anal canal structure and external anal sphincter. The purpose of this study was to compare findings at anal endosonography with electromyographic tests in patients with faecal incontinence. METHODS: Fourty patients (31 women; median age: 47 years) were referred for exploration of the anal sphincter: 15 patients had previous anal surgery, 16 patients had obstetrical trauma, 3 patients had accidental trauma, 6 women had obstetrical trauma and previous anal surgery. RESULTS: Anal endosonography demonstrated an external sphincter defect in 19 patients (partial n = 4, complete n = 15); 18 of these patients had an electromyographic study: an external sphincter defect was demonstrated by mapping in 15 cases; 3 partial defects were not found. Eight patients had associated pudendal nerve terminal motor latency delayed due to neuropathic impairment of pudendal nerve. Surgery was performed in 12 patients; external sphincter lesion was confirmed in all cases. CONCLUSIONS: Anal endosonography and electromyography mapping easily recognize external sphincter disruption with high concordance. Partial defects are better diagnosed by anal endosonography. A study of pudendal nerve terminal motor latency is useful in the exploration of faecal incontinence because pudendal neuropathy occurs frequently in association with a sphincter defect.

[Extracorporeal lithotripsy of gallbladder calculi. Tolerability, complications and early results]. / Lithotritie extracorporelle pour lithiase vésiculaire. Tolérance, complications et résultats précoces.

The purpose of this prospective study, conducted on 88 patients, was to assess the tolerance, efficiency and early complications due to a piezo-electric lithotriptor in the destruction of gallbladder stones. One hundred and sixty one sessions were performed in 82 patients. All patients had symptomatic, uncomplicated lithiasis, the diameter of which was less than, or equal to, 30 mm. All patients had less than 7 stones in a functional gallbladder. In 22 patients, the stones were calcified. Lithotripsies were carried out without anesthesia or premedication, except in an 8-year-old child who had to be anesthetized. In 3 cases it was impossible to visualize the gallstones and in 3 other patients, the procedure was discontinued because of abdominal pain. Following the procedure, biliary pain occurred in 20 per cent of the patients. One patient only had biliary colic with transient anicteric cholestasis. Clinical examination, sonography, biological tests were found to be normal in all other patients. Endoscopic sphincterotomy or emergency surgery was never required. Stones were found to be unaltered in 6 patients following 2 lithotripsy sessions. The 76 other patients had fragmentation of their stones. The free gallbladder rate was 15.8 per cent between 0 and 2 months, 24.6 per cent between 2 and 4 months and 51.3 per cent between 4 and 8 months. These results tend to show that the destruction of biliary stones by piezo-electric lithotriptor is efficient and well tolerated. As repeated routine examinations were always negative, the three-day hospitalisation period no longer seems necessary.

[Retrorectal tumor in adults. Combination of computed tomography and endorectal echography]. / Tumeur rétrorectale de l'adulte. Intérêt de l'association tomodensitométrie et échographie endorectale.

A retrorectal tumor was identified by presacral palpation in a 41-year old woman. Combined preoperative computed tomography and intrarectal ultrasound accurately delineated regional and local spread, respectively. This combined approach confirmed diagnosis and provided guidance for total ablation of a mature cystic teratoma.

[Sixty-one cases of acute obstructions of the colon caused by cancer. Indications for emergency surgery]. / Soixante et une occlusions aiguës du côlon par cancer. Indications chirurgicales en urgence.

Sixty-one cases of acute malignant colonic obstruction were operated upon within 24 hours after the patient's admission, between 1979 and 1989: 10 for a right colon carcinoma, 51 for a left-sided lesion. Indications, for emergency operation were: complete clinical obstruction, iliac tenderness, radiologic ileal fluid levels and arrest on barium enema. The initial procedures consisted of 8 right hemicolectomies, and for the left-sided obstructions, 32 colostomies, 7 colectomies with immediate anastomosis, and 12 colectomies without anastomosis. Overall mortality was nil for the right side and 4% left-sided obstructions. The current surgical procedures of choice according to the authors are: right hemicolectomy for right-sided obstruction; elective colostomy for the left side. In case of doubt about the mechanism of obstruction or vitality of the colon, a midline approach for operative exploration, followed by colectomy without anastomosis is recommended. Colectomy with immediate anastomosis is possible in rare favourable cases. Subtotal colectomy is indicated in cases of ischemic lesions, caecal perforation or other colonic tumours. Intraoperative irrigation of the colon is rarely permitted in this particular variety of acute obstruction.

[Treatment of complicated peptic esophagitis. Role of total duodenal diversion]. / Traitement des oesophagites peptiques compliquées. Place de la diversion duodénale totale.

Total duodenal diversion was performed in 60 patients with reflux oesophagitis complicated by stricture, brachyoesophagus, endobrachyoesophagus or previous oesophago-gastric surgery. The standard operation (truncal vagotomy, antrectomy, 70 cm Roux-en Y anastomosis) was carried out in 41 patients; technical adjustments were necessary in 19 patients previously operated. One patient died of post-operative pulmonary embolism. Lasting cure of the oesophagitis was obtained within less than 3 months in 56/59 patients (93 per cent). Three-hour post-prandial pH measurements showed control of the reflux in 48/52 patients (92 p. 100). Anastomotic ulcers developed in 3 patients who did not have vagotomy. One case of complete remission of endobrachyoesophagus was observed, and 4 cases are now in partial remission. Digestive tract sequelae were found in 9 patients who had undergone surgery, but they were disabling in only one of these. These results suggest that total duodenal diversion is a suitable treatment of complicated reflux oesophagitis.

[Anal metastases from cancer of the colon]. / Métastases anales de cancer du côlon.

Two cases of anal metastases from sigmoid carcinoma are reported. The two patients were treated by local excision. The various mechanisms of tumoral spread are discussed from a review of the literature; the most frequent mechanism is cellular exfoliation. The most commonly used therapeutic approach is local excision combined, if necessary, with reconstruction of the sphincters.

[Mirizzi's syndrome]. / Le syndrome de Mirizzi.

Six cases of Mirizzi syndrome are reported. The syndrome consists of a special anatomical variant of the cystic duct, which has a low opening but runs side-by-side with the common bile duct, associated with entrapment of a gallstone in the cystic duct or the neck of the gallbladder, partial or total obstruction of the hepatic duct by the stone and by inflammatory lesions, and recurrent cholangitis. Clinical signs are non-specific and suggest at first sight an obstructive jaundice. Pre-operative morphological examination seldom provide a diagnosis before surgery. In the most typical cases ultrasonography shows dilatation of the upper biliary tract with narrowing of the hepatic duct below the dilatation, due to a stone located outside the common bile duct. Opacification of the biliary tract by endoscopic retrograde catheterization of the papilla duodeni or by transparietohepatic puncture give suggestive images (non-opacification of the cystic duct, narrowing of the hepatic duct opposite the extrinsic compression, with overlying dilatation), but these images are not specific. The per-operative diagnosis is difficult owing to the inflammatory lesions, and a diagnosis of cholangiocarcinoma may be envisaged. Cholecystectomy with recanalization of the cystic duct suppresses the extrinsic compression and helps the inflammatory lesions to regress. However, opening and draining the common bile duct is often necessary.

[Acute gangrenous acalculous cholecystitis disclosed by postoperative septic shock]. / Cholécystites aiguës gangréneuses alithiasiques révélées par un choc septique postopératoire.

Three cases of acute gangrenous acalculous cholecystitis, revealed by a postoperative septic shock, are reported. Clinical examination was negative and the surgery gave the diagnosis. Infection with biliary stasis and ischaemia accounts for this pathological entity. The very serious prognosis of this condition can only be reversed by cholecystectomy.

[Adenocarcinoma of the duodenum. 17 cases]. / Adénocarcinome du duodénum. Dix-sept observations.

Seventeen cases of duodenal adenocarcinoma are reported and compared with cases from the literature. Ten tumours were located in the second part of the duodenum, 9 were around the hepatopancreatic ampulla, 4 were above and 4 below this ampulla. Four tumours (23 per cent) had limited intramural expansion (Dukes' stage A or B) and 6 (35 per cent) involved the lymph nodes. The major clinical signs were loss of weight (11 cases), signs of obstruction (9 cases), bleeding (6 cases) and jaundice (6 cases). The paraclinical examinations that were determinant for the diagnosis were gastroduodenal radiographic study (16 cases) and endoscopy with biopsy (9 cases). Computerized tomography was useful for preoperative evaluation. The respective values of these examinations for early diagnosis and excisability of these tumors are discussed. All 17 patients were operated upon: 11 (64.7 per cent) underwent radical excision, 5 had duodenal bypass and 1 had exploratory laparotomy. The overall operative mortality rate was 5.8 per cent, with no deaths for bypasses and excisions. Mean survival after bypass was 5 1/2 months. The one year survival was 63.5 per cent in 5 patients with excision and 83.3 per cent in 6 patients with cephalic duodenopancreatectomy, but none of these patients survived for more than 5 years.

[Trocar-induced complications in laparoscopy]. / Les complications dues aux trocarts en laparoscopie.

Trocar-related injury can occur if the different procedures, including distension of the abdomen, pneumoperitoneum or anesthesia, are insufficient. Such injuries can be prevented by proper handling and good angulation of the trocar on the abdomen. In case of suspected vascular injury, conversion to open laparotomy is required to explore the abdominal cavity. If abdominal adhesions are discovered after introducing the first trocar, a second trocar must be introduced at some distance from the first one to visually check the absence of any digestive injury. The degree of wound dehiscence depends on the size, site and direction of introduction of the trocar.

[Pretherapeutic endosonography in rectal adenocarcinoma]. / L'échographie endocavitaire dans le bilan pré-thérapeutique de l'adénocarcinome rectal.

The advent of transrectal ultrasonography has contributed to improving therapeutic management of cancer of the rectum. The 7.5 MHz transrectal probe evidences five tissue layers in the rectal wall. The 10-12.5 MHz probe can visualize seven layers. Transrectal ultrasonography can also be used to explore the perirectal environment and detect possible nodes. Echographically, the tumor is seen as an hypoechogenic mass invading the rectal wall outwardly, disorganizing the wall structures. Parietal recurrence is seen as a hypoechogenic heterogeneous thickening. Ultrasonographic surveillance can be proposed for operable patients with a high risk of recurrence. Cautious interpretation is required due to the known limitations of transrectal ultrasonography. Truly invaded nodes may not be seen due to their small size (less than 2-3 mm) or their localization far from the probe (false negatives). Transrectal ultrasonography provides important information for therapeutic decision making in terms of surgical access and/or indications for possible adjuvant therapy. Transanal resection may also be ruled out if there are perirectal nodes. Patients may also be selected for preoperative radiotherapy, possibly associated with chemotherapy.

[Ogilvie's syndrome or colonic pseudo-obstruction. Apropos of 26 cases]. / Syndrome d'Ogilvie ou de pseudo-obstruction colique. A propos de 26 observations.

From twenty six personal cases, the authors make a review of the literature. 92% of their cases are met in a post operative (28%), neurological (28%), general (24%) context, or in intensive care with assisted ventilation (36%). The major symptom is the meteorism (100%) with in one out of three cases, abdominal pain, vomiting, right iliac defense, absence of bowel sounds. Radiological distension involves mostly the right colon and the coecum (28%), right and transverse colon (40), sometimes the whole colon (32%). The mean diameter of the coecum reached 12 cm (9 to 25 cm). Early coloscopy was mandatory in 20 patients, of which 14 were cured, 13 patients were operated on, for suspicion of ischemia or perforation, because incertain diagnosis, or failure of colonoscopy. Ceocostomy or right hemicolectomy (55%) were performed rather than transverse colostomy. The surgical approach must be adapted to the anatomical lesions. Total mortality was 4% in this series. Early diagnosis of pseudo obstruction, early colonoscopy with intubation must allow to avoid surgery.

[Ischemic colitis. A surgical series of 88 cases]. / Colites ischémiques. Une série chirurgicale de 88 cas.

We report our experience in 88 cases of ischemic colitis including 76 cases of gangrene with 17 perforations, 6 cases with stenosis and 6 cases which regressed. The left colon was involved in 59 cases with extension to the transverse colon in 20 the right colon in 10 and global involvement in 18. Abdominal pain, diarrhea, and meteorism occurred in 81, 62 and 78% of the cases respectively. Coloscopy was performed in 61 cases, a barium study in 27. A colectomy was required in 77 patients: 50 left colectomies with 16 extensions to the transverse colon, 17 total colectomies and 10 right colectomies. Morbidity was 53% in cases with perforated gangrene and 28% without perforation. There was no morbidity in stenosis and regressive forms. Normal tube flow was conserved or reestablished in 51 of the 62 survivors. The 88 patients were referred from cardiovascular units (36%), intensive care (28.5%), or internal medicine (22%). All had intramural ischemia due to local or general lesions which progressed to parietal gangrene in 76 cases. The diagnosis was based on clinical signs and confirmed by coloscopy which determined the stage and extension. Stage II ischemia required rapid colectomy adapted to the endoscopic lesions and not the exterior aspect of the colon; immediate anastomosis is usually not used.

[Evolution of Hartmann's procedure. 249 interventions]. / Evolution de l'intervention de Hartmann. 249 interventions.

A retrospective study of 249 patients undergoing Hartmann's procedure over twenty-five years was undertaken to analyse the evolution of indications and results. Patients were divided into three time period groups: from 1969 to 1978, 1979 to 1990 and 1991 to 1994. Mean age was 68 years old. Major indications were complicated diverticular disease (42.9%), colo-rectal malignancies (35.7%) and ischemic colitis (14%). Operative mortality is 10.8%, higher in ischemic colitis (20%) than in complicated diverticulitis (6.5%) and cancer (13.4%). Overall morbidity has significantly reduced, from 65.51% to 17.24%. General complications have changed a little, while local and/or inherent operative complications have reduced from 22.4% to 1.72. Restoration of colorectal continuity was done in 59.54% of patients, increasing from 36% to 71% during the three periods. This is variable depending on initial disease: 92% in diverticular disease, 69% in ischemic colitis but remains stable for carcinoma at 33%. Overall mortality since 1981 is 2.5% and morbidity is 19.13%. Mean Hospital stay was 20 days for the initial operation and 15 days for secondary restoration of colorectal continuity. Hartmann's procedure is well indicated as emergency surgery in colonic perforations, abscessus and ischemia. Progressive improvement of its results is essentially due to persistent attention to indications and technical details.